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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201280
Report Date: 02/14/2025
Date Signed: 02/14/2025 06:01:44 PM

Document Has Been Signed on 02/14/2025 06:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LEAP CARE SERVICES LLCFACILITY NUMBER:
019201280
ADMINISTRATOR/
DIRECTOR:		ECHON, RICARDOFACILITY TYPE:
740
ADDRESS:4336 EAST AVENUETELEPHONE:
(925) 223-7791
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 6CENSUS: 5DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Marivel Calambro, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 2/14/2025 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with caregiver, Catherine Ibanez and explained the purpose of the visit. Administrator, Marivel Calambro arrived 30 minutes later. The facility’s fire clearance was approved for 6 residents of which 4 residents maybe non-ambulatory and 2 residents maybe under hospice care.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full. One week of nonperishable and 2-day of perishable food supplies were available. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned. First Aid kit is complete. LPA reviewed 5 residents and 3 staff files starting at 11:30AM.

At 12:15PM, LPA observed unlocked medications in the refrigerator. Staff locked up the medications during inspection.

At 12:20PM, LPA observed unlocked knives and scissors in the kitchen. There was unlocked cleaning supplies in the bathroom and unlocked tools in the backyard. Staff locked up the items during inspection.

At 12:25PM, LPA measured hot water temperature at 130.5 degrees F in the hallway bathroom. Staff lowered hot water temperature and LPA re-measured hot water at 118.1 degree F.

At 12:45PM, LPA observed R1's physician's report dated 7/19/2024 states R1 has a dementia diagnosis which requires R1 to be in a non-ambulatory room. However, R1 is occupying room 5 which is ambulatory only. Civil penalty of $500 is being assessed.
(continue on LIC809C...)
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 02/14/2025 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 02/14/2025 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LEAP CARE SERVICES LLC
FACILITY NUMBER: 019201280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having hot water at 130.5 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/15/2025
Plan of Correction
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Administrator lowered hot water and LPA re-measured hot water at 118.1 degrees F in the hallway bathroom.
Deficiency cleared.
Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having a non-ambulatory resident in an ambulatory room which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/15/2025
Plan of Correction
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Administrator has agreed to submit LIC200 and updated sketch to CCLD by POC date.
Civil Penalty of $500 is being assessed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 02/14/2025 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 02/14/2025 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LEAP CARE SERVICES LLC
FACILITY NUMBER: 019201280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked knives, scissors, cleaning supplies, and tools at the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/15/2025
Plan of Correction
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Staff locked up the items during inspection.

Deficiency cleared.
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/15/2025
Plan of Correction
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Staff locked up the medications during inspection.

Deficiency cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/14/2025 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 02/14/2025 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LEAP CARE SERVICES LLC
FACILITY NUMBER: 019201280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test completed for S3 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Administrator has agreed to obtain health screening and TB test for S3. Administrator will submit a copy to CCLD by POC date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 02/14/2025 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 02/14/2025 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LEAP CARE SERVICES LLC
FACILITY NUMBER: 019201280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having TB test on file for R1, R2, and R4 which poses a potential health and safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Administrator has agreed to obtain TB test for R1, R2, R4 and submit copies to CCLD by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting disaster drill every three months which poses a potential health and safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Administrator has agreed to conduct a disaster drill and submit document to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: LEAP CARE SERVICES LLC
FACILITY NUMBER: 019201280
VISIT DATE: 02/14/2025
NARRATIVE
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At 1:00PM, LPA observed R1, R2, and R4 does not have TB test on file.

At 1:10PM, LPA observed resident files were incomplete.

At 2:00PM, LPA observed S3 does not have health screening and TB test on file.

At 2:10PM, LPA observed S1, S2, and S3 does not have current first aid training on file.

At 2:30PM, LPA observed facility did not conduct fire drill every three months.

LPA will return at a later time to complete annual inspection.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report, civil penalty, and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 02/14/2025 06:01 PM - It Cannot Be Edited


Created By: Grace Luk On 02/14/2025 at 05:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LEAP CARE SERVICES LLC
FACILITY NUMBER: 019201280

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having current first aid training for 3 staff which poses a potential health and safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Administrator has agreed to obtain current first aid training for S1, S2, S3 and submit copies to CCLD by POC date.
Type B
Section Cited
CCR
87506(d)
(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having incomplete resident files which poses a potential health and safety risk to persons in care.
POC Due Date: 03/07/2025
Plan of Correction
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Administrator has agreed to review resident files and make sure all files are complete. Administrator will submit self-certification to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2025


LIC809 (FAS) - (06/04)
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